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Ul <br /> San Joaquin County 111"W <br /> z' = Environmental Health Dep,rtn <br /> SITE <br /> f - � -,111 r� <br /> � : < 304 East Weber Avenue, 3rd Floor, Stockton,CA o t� �._,iw ! .`r�LDMITIGATION <br /> (209}468-3449 Fax: (209}X168-3433 Web: www.sjgoy.org/ehd u � UNIT IV <br /> Well Permit Application DEC 9 2004 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATM6'69NE EII I HEAL.TId <br /> ri g C D lLQ made in compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and;or install the work doss i e app i F <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �1i�! �} (� e, Assessors <br /> WELL Location oC fad C�aniji n 2. l�C(_ _Cross Street ;? City ra 6 <br /> Zip S�� Parcei# Z3 r- O Z e)-o(� <br /> PROPERTY4 <br /> Owner 3T Skds 0.q e. _Address a'J(oo oLs+p- Z c City l'ac-�—Zip ;Mlehone# 5 1 <br /> C-57Contractor C&S.C.O IL Address&o32- ��r1QL 1rc1G City dle�a _Zip957�ZLi 1711510 PhoncklIG-—02- <br /> Consultant!Sub Cntr A GC _.Address S ,aw City� Lick9C).2.2'7 Phone# Y&7-1400 0 <br /> GIS Coordinates:X ,Y_ _,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HANG-AUGER,OTHER`) ;DESTRUCTION (choose type below) <br /> 0 SOIL BORING# %OVER-BORE. DIAMETER <br /> WELL# MW- [l PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS 4aI Z99 16` GX <br /> CCMNl1ENTS: 0V1tr&ri 5\ }ri'sa� t `r1-• cs,ic l �n C en'E n S, w e l 1 <br /> 11PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING I]HOLLOW STEM DIA.OF BOREHOLES 0 MIULTIFLE CA&NGS 0 MUL T I-LEVE! VjELL CASING GIA:_ <br /> 0 LXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: UST EEL a PVC 0.OTHER: <br /> 3 VAPOR 0 MUD ROTARY DEPTH OF GROUT TREMIE TYPE TO BE USED: 0 AUGERS 0 HCSE <br /> 0 AiR SPARGE!OZ^aNE 0 PUSH POINT(GP or CPT)GROUT SEAL_PUMPED: 0 Yes 0 No INCTE: MAXIMUM FRER-FALL DEPTH IS 30') <br /> 11 SCIL BORING 0 HAND AUGER GROUT SPEC:FICATICNS <br /> 0 OTHER: 0 OTHER P.PPROX.BORING E?T:� F 0 30L TED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> C--M M ENTS: <br /> 10TE: OFFS]T E EORINGS RE�CUIRE ACCESS Ai REEMEN ` OR ENCROACHMENT T r Ers I1TS. <br /> 43 WORKING HOURS NOTICE REQUIRED FOR INSPECT IONS. <br /> I thereby cart' I have prepared alae application and that the wcrk Will be done in accordance with San Joaquin <br /> County Or s, RCI an tiars, and all applicable California State Laws. <br /> Signed x TitlelCompany P..n� t <br /> AG <br /> Print Nam '�ire Date_1 Z-7' O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: `i 2 3 b <br /> Application Accepted By Date Issued _ !d Y Area 6 Zt <br /> Grout Inspection By (l� -�,..� Date 1 OS— Final Inspection By Date_ 1 1057- <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUESTS INVOICE <br /> 60.C>fJ a%Lk 7 8 {a r ory S R# O b i $ <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6122104 <br />